PART 3. June 6, 2019. CANDIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.” (D)

ASSIGNMENT: How should a hospital respond to the New York State initiative to prevent the spread of Candida auris, when there are no evidenced based best practices?

New PART 3 after PARTS 1 & 2

ART 1. April16, 2019. Is it ethical for the public not to be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

PART 1. April16, 2019.  Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.”” (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected-someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases – now the third-highest after New York and Illinois – has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials…

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.” (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts – funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention – are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.” (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent…

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital – or an entire town – who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois – all in the Chicago area – a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities – such as skilled-care nursing homes or long-term acute-care hospitals – and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…” (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention – the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively – infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible – the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida – the regular ones – are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

PART 2. In 30 years, I’ve never faced so tough a reporting challenge – and one so unexpected. Who wouldn’t want to talk about a fungus?…

“C. auris is a drug-resistant fungus that has emerged mysteriously around the world, and it is understood to be a clear and present danger. But Connecticut state officials wouldn’t tell us the name of the hospital where they had had a C. auris patient, let alone connect us with her family. Neither would officials in Texas, where the woman was transferred and died. A spokeswoman for the City of Chicago, where C. auris has become rampant in long-term health care facilities, promised to find a family and then stopped returning my calls without explanation.” (A)

“Candida auris, also referred to as C. auris, is a potentially deadly fungal infection that appears to be making its way through hospitals and long-term care facilities across the country. The New York City area and New Jersey have reported more than 400 cases over the last few years alone. Federal health authorities have declared this fungus a “serious global health threat.”” (B)

“The Council of State and Territorial Epidemiologists (CSTE) says Candida auris infections have been “associated with up to 40% in-hospital mortality.”

“Most strains of C. auris are resistant to at least one antifungal drug, one-third are resistant to two antifungal drug classes, and some strains are resistant to all three major classes of antifungal drugs. C. auris can spread readily between patients in healthcare facilities. It has caused numerous healthcare-associated outbreaks that have been difficult to control,” the CSTE said.

The CDC added, “Patients who have been hospitalized in a healthcare facility a long time, have a central venous catheter, or other lines or tubes entering their body, or have previously received antibiotics or antifungal medications, appear to be at highest risk of infection with this yeast.”

The CDC is alerting U.S. healthcare facilities to be on the lookout for C. auris in their patients.” (C)

“”It’s a very serious health threat,” said Dr. Irwin Redlener, Columbia University professor and an expert on public health policy. “It’s a superbug, meaning resistant to all-known antibiotics.”..

“These people would be in danger, so you don’t want somebody visiting the hospital not knowing that it’s around and somehow contracting the infection,” Dr. Redlener said. “That would be an utter disaster.”..

Dr. Redlener says the secrecy is a big mistake.

“If they’re rattled by Candida auris to the point where we have secrecy pacts among hospitals and public health agencies, then you’re just hiding something that obviously needs more attention and resources to deal with,” he said.

The state Department of Health says there is no risk to the general public and notes that the vast majority of patients have had serious underlying medical conditions.

Jill Montag, a spokesperson for the New York State Department of Health, issued a statement to Eyewitness News.

“We are working aggressively with impacted hospitals and nursing homes to implement infection control strategies for Candida auris,” it read.

Montag says they plan to include the name of the impacted facilities in their annual infection report, which will be released later this year.

Dr. Redlener says they have the information now and should release the names now…

“To keep that a secret is putting people in danger,” he said. “And I don’t think that’s reasonable or ethical.”” (D)

“We don’t know why it emerged,” said Dr. Maurizio Del Poeta, a professor of molecular genetics and microbiology at Stony Brook University’s Renaissance School of Medicine. At the very least, he is recommending hospitals develop stricter rules on foot traffic in and out of patients’ rooms because the microbe can be carried on the bottom of shoes.

The pathogen clings to surfaces in hospital rooms, flourishes on floors, and adheres to patients’ skin, phones and food trays. It is odorless, invisible – and unlikely to vanish from health care institutions anytime soon.

“It can survive on a hospital floor for up to four weeks,” Del Poeta said of C. auris. “It attaches to plastic objects and doorknobs.”..…

“If we don’t want it to become like Staphylococcus aureus, then we have to act now,” said Del Poeta, referring to the bacteria that became the poster child of drug resistance when it developed the ability to defeat the antibiotic methicillin, garnering the name methicillin-resistant Staphylococcus aureus, or MRSA…

“In order to get Candida auris out of a room, you have to take away everything – doorknobs, plastic items, everything. It is very difficult to eradicate it in a hospital,” Del Poeta said. He said his institution has never had a patient with C. auris…

Scientists such as Del Poeta contend it’s time for new methods of addressing resistant microbes of all kinds because infectious pathogens have developed the power to outwit, outpace and outmaneuver humankind’s most potent agents of chemical warfare, many of them developed in the 20th century.” (E)

“A case management program piloted by the New York City health department monitors patients colonized with Candida auris after they are discharged into the community and notifies health care facilities of their status, researchers reported at the CDC’s annual Epidemic Intelligence Service conference….

Patients can remain colonized with C. auris for months in a health care setting, but it is unclear if they remain colonized after discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service officer with the New York City Department of Health and Mental Hygiene (DOHMH), and colleagues.

According to Bergeron and colleagues, the state health department began referring patients colonized with C. auris to the DOHMH on Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting patient interviews and reviewing medical records to obtain relevant clinical information. They informed the patients’ providers and health care facilities about their C. auris status and infection control needs.

“We requested that facilities flag the patient in their electronic medical records to ensure that the patient has the proper precautions, if the patient were to seek care again at those facilities,” Bergeron said in a presentation. “Case mangers sent a medical alert card to the patients for them to use when encountering health care providers unaware of their infection control needs.”” (F)

“Regions are considering the use of electronic registries to track patients that carry antibiotic-resistant bacteria including carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can be challenging and requires time, effort, and resources; therefore, there is a need to better understand the potential impact…

When all Illinois facilities participated (n=402), the registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in a 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. When 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and 2.8% relative reduction in prevalence.

Implementing an XDRO registry reduced CRE spread, even when only 25% of the largest Illinois facilities participated due to patient sharing. Non-participating facilities garnered benefits, with reductions in new carriers.” (G)

“Quebec public-health authorities are bracing for the inevitable arrival of a multi drug-resistant fungus that has been spreading around the globe and causing infections, some of them fatal…

“We will definitely have cases here and there at one point,” said Dr. Karl Weiss, chief of infectious diseases at the Jewish General Hospital. “It’s almost guaranteed. The only thing is when you know what you’re fighting against, it’s always easier and we will be able to contain it a lot faster.”

C. auris poses a quadruple threat: it’s tricky to identify; it can thrive in hospitals for weeks (preying on patients with weakened immune systems); it’s resistant to two classes of anti-fungal medications; and it can cause invasive disease, with lingering bloodstream infections that are hard to treat. The mortality rate can rise as high as 60 per cent.

The pathogen has emerged at a time when hospitals in Quebec – their budgets stretched more than ever – are already struggling with antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused outbreaks. The Institut national de santé publique du Québec published a bulletin last year on steps that hospitals and long-term centres can take to prevent C. auris outbreaks.

“The problem is if you don’t identify the fungus properly, then it can slip in between your hands, and you can have an outbreak in your institution without even knowing it,” Weiss explained.

There was a lot of mis-indentification of this with other Candida (fungi); and even the automated systems in institutions that identify bacteria and yeast were mislabelling this Candida for something else. For a while, people were not aware of this auris. But now we know how to identify it.

“The first thing we did in Quebec – and this was for all the microbiology labs – is we taught all the microbiologists how to properly identify Candida auris,” Weiss continued. “All the major labs in Quebec put in place protocols.”

Weiss, who is president of the Quebec Association of Medical Microbiologists, noted that under a quality assurance program, samples have been sent to different labs to test whether the fungus is identified correctly. The results show that that labs are detecting C. auris to a high degree.

If a patient is discovered to be infected, hospital protocol dictates that the patient be isolated. During the patient’s hospitalization, the housekeeping staff must disinfect the room daily with hydrogen peroxide and other chemicals…” (H)

“Federal officials should declare an emergency over a deadly, incurable fungus infecting people in New York, New Jersey and across the country, Sen. Chuck Schumer said Sunday.

Schumer said he’s pushing the federal government to allocate millions of dollars to fighting Candida auris, which is drug-resistant and proving very difficult to eradicate…

“When it comes to the superbug, New York could use a little more help,” said Schumer. “The CDC has the power to declare this an emergency and automatically give us the resources we need.”..

Schumer said that an emergency declaration by the CDC would lead to more cases being identified with better testing, and to better tracking of the disease. It might also reduce the number of unnecessary antibiotic prescriptions, which Schumer says have helped the disease become drug-resistant…

Schumer cited other CDC emergency declarations that helped stop the spread of deadly diseases, including a $25 million award to fight the Zika virus in 2016 and $165 million given to contain Ebola in 2014.

“Every dollar we can use to better identify, tackle and treat this deadly fungus is a dollar well spent,” Schumer said.” (I)

“Other medical experts see the overuse of human antifungal medications in agriculture and floriculture as potential reasons for resistance in Candida auris, known as C. auris, and possibly other fungi.

Dr. Matt McCarthy, a specialist in infectious diseases at Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the Netherlands, are dosed with the same antifungal medications developed to treat human infections.

“Antifungals are pumped into tulips in Amsterdam to achieve flawless plants,” he said. “As a fungal expert, I know that we have very few antifungal medications, and this is a misuse of the drugs.”

Studies conducted at Trinity College in Ireland support McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from the Netherlands may be vehicles that spread drug-resistant fungi.

Trinity scientists, who examined resistance in another potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs repelled the drugs known as triazoles. The fungi became resistant because of the overuse of triazoles in floriculture. As with C. auris, drug-resistant A. fumigatus can be deadly in people with poor immunity.

When patients need treatment with triazole-class medications, the drugs don’t work because the fungi have been overexposed in the environment, McCarthy said.

He added that the use of antifungal medications in floriculture is similar to the overuse of antibiotics in the poultry and beef industries, which have helped drive resistance to those drugs.

The floriculture example is just one way that drug-resistant fungi can spread around the world. Global trade networks, human travel and the movement of animals and crops are others.” (J)

“It will take further research to determine if the new strains of C. auris have their origins in agriculture, but Aspergillus has already illustrated the perils of modern farming. Antibiotics are applied on a massive scale in food production, pushing the rise of bacterial drug resistance. A British government study published in 2016 estimated that, within 30 years, drug-resistant infections will be a bigger killer than cancer, with some 10 million people dying from infections every year.

We don’t have to end up there. Pesticide use on most farms can be greatly reduced, or even eliminated, without reducing crop yields or profitability. Methods of organic farming, even as simple as crop rotation, tend to promote the growth of mutualistic fungi that crowd out pathogenic strains such as C. auris. Unfortunately, because conventional agriculture is heavily subsidized and market prices don’t reflect the costs to the environment or human health, organic food is more expensive and faces an uphill battle for greater consumption.

Of course, improved technology could help, with drugs of new kinds or in breeding and engineering resistant strains of plants. There’s also plenty of opportunity for lightweight agricultural robots, which can weed mechanically or spray pesticides more accurately, reducing the quantity of chemicals used. But tech shouldn’t be the sole focus just because it happens to be the most profitable route for big industries.” (K)

“The recent outbreak of the so-called superbug – and other drug-resistant germs – has thrown a spotlight on locally based Xenex Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet rays to disinfect surgical suites and other environments that are supposed to be germ-free.

With the spread of C. auris, Xenex officials say they’ve seen an uptick in queries about their LightStrike Germ-Zapping Robots, which are in use at more than 400 health-care facilities around the world since manufacturing started in 2011.

These devices – often called R2Clean2, Mr. Clean and The Germinator – disinfect rooms in a matter of minutes. A dome on the top of the robot rises up, exposing a xenon bulb that emits UV light waves that kill germs on contaminated surfaces.

Bexar County-owned University Hospital has a fleet of six Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to help protect patients from infection by other patients.

“We are taking every measure possible to reduce the risk of infections, and this is an additional layer of security that bathes the room in UV-C light,” said Elizabeth Allen, public relations manager at University Health System…

Another study, recently published by a doctor at the Minnesota-based Mayo Clinic, showed that when the hospital used the robots in rooms that had already been cleaned, infection rates of another superbug – called Clostridium difficile, or C. diff – fell by 47 percent.” (L)

“It wasn’t publicized locally, but within the past few years teams of health officials at two Oklahoma health facilities took rapid actions to contain the spread of a fungal “superbug” that federal officials have declared a serious global health threat.

Only one patient at each facility was infected, and both patients recovered. But the incidents reflect the growing alarm among health officials over the deadly, multidrug-resistant Candida auris, or C. auris, which can kill 30 percent to 60 percent of those infected…

In April 2017, a team of experts from the federal Centers for Disease Control and Prevention converged on the University of Oklahoma Medical Center in Oklahoma City after a patient tested positive for the drug-resistant fungus.

About a year later, a patient at a southeast Oklahoma health facility tested positive for the germ during a routine test. In both cases, health officials isolated the patients, locked down their rooms and ordered dozens of lab tests to see if the multidrug-resistant fungus had spread…

Unlike with outbreaks in Illinois, New York and New Jersey, the potentially deadly infection was quickly contained.”..

Public knowledge about the OU Medical Center case makes it an exception. Typically, health care facilities across the nation don’t release to the public information when C. auris and other drug-resistant pathogens are found. No law or policy requires them to do so.

Patient-rights advocates maintain that the public has the right to know when and where outbreaks or even single cases occur. But health officials have routinely fought back, suggesting that it could violate patient rights and discourage patients from seeking hospital care.

But the CDC allows states to make that decision.

Burnsed said the Department of Health tries to walk a tight line between notifying the public and protecting the patient’s privacy.

He said he would be more likely to identify a facility if it’s anything more than an isolated case or if officials believed the exposure wasn’t contained.

“What we consider is if there was a risk to a broader group of individuals and if there was any evidence that there were a breach in lab controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s two cases) because we didn’t think there was a greater risk to the public, but it’s a good question to consider.”” (M)

“How many people will needlessly die from a deadly bug sweeping through New York hospitals and nursing homes before local health officials acknowledge the danger publicly – and act accordingly?..

Yet public-health officials here have been slow to let patients know in which hospitals the bug is lurking. Folks are left to take their chances. That’s outrageous.

Why are officials mum? Partly because they fear that if they disclose the information, some people who need treatment won’t go for it.

That’s a weak excuse: As McCaughey notes, there are plenty of local hospitals that aren’t plagued by Candida auris, so patients could get care and avoid the risk, if they know where it’s safe to go.

More likely, no one wants to damage the reputations (or incomes) of the affected hospitals. Yet the best way to protect those reputations is to make sure the facilities are Candida auris-free…

Meanwhile, officials say they will reveal which hospitals have the germ – in their next yearly report. But that could be months away; patients need to know now.

If neither the hospitals nor their government regulators are willing to move sooner, perhaps state lawmaker should step in and require them to do so… (N)

Infectious disease experts tell Axios they agree with a dire scenario painted in the UN report posted earlier this week saying that, if nothing changes, antimicrobial resistance (AMR) could be “catastrophic” in its economic and death toll.

Threat level, per the report: By 2030, up to 24 million people could be forced into extreme poverty and annual economic damage could resemble that from the 2008–2009 global financial crisis, if pathogens continue becoming resistant to medications. By 2050, AMR could kill 10 million people per year, in its worst-case scenario.

“There is no time to wait. Unless the world acts urgently, antimicrobial resistance will have disastrous impact within a generation.”..

By the numbers: Currently, at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people from multidrug-resistant tuberculosis, per the UN. Common diseases – like respiratory infections, STDs and urinary tract infections – are increasingly untreatable as the pathogens develop resistance to current medications.

The Centers for Disease Control and Prevention says AMR causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…

What needs to be done: Jasarevic says the economic and health systems of all nations must be considered, and targets made to increase investment in new medicines, diagnostic tools, vaccines and other interventions.”

The bottom line: Action must be taken to avoid a catastrophic future.” (O)

“A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.

Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.

What many might not realize, though, is that health care workers’ attire – including that seemingly “clean” white coat that many prefer – can harbor dangerous bacteria and pathogens.

A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.”

It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.

Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours…

It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers – including wearable sanitizer dispensers – could help reduce the spread of harmful bacteria.

Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.” (P)

PART 3. May 28, 2019. CADIDA AURIS. “Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn’t have them, it isn’t looking hard enough.”

“So far, 12 states from coast to coast have had confirmed cases of Candida auris, which has spread with particularly speed in New York, which has had more than half of the nation’s infections.

Some are even calling for the federal government to declare a national state of emergency and fund better containment of the fungus. 

Health officials there are scrambling to contain what the Centers for Disease Control and Prevention (CDC) have deemed an emerging health threat, but without stricter guidelines and screening, the fungus will only get more deadly…

Doctors sometimes struggle to diagnose fungal infections, in part because their symptoms are little different from those of bacterial infections…

‘Candida auris has the ability to develop resistance and has developed mechanisms to survive,’..

‘It’s at least starting to figure that out, and that’s obviously concerning.’

There are really only three antifungal medications in the US, so it doesn’t take long for a fungus to become wholly drug resistant.

Dr Chiller says that approximately 90 percent of strains the CDC has logged are resistant to the first-line drug, another third are resistant to a second, and between 20 and 30 percent of Candida auris infections have acquired multi-drug resistance.

‘Some are pan-resistant and those need to be isolated and stopped and we need to try to prevent them from developing,’ he says. 

Neither the CDC, other nation’s health officials or any of the 12 affected states have been able to work out where the fungus came from, or how exactly it has spread from state-to-state… 

If states don’t require their hospitals to report cases the fungal infection, the CDC may be severely underestimating the number of cases across the country.

‘It’s a bit of an uphill battle and it needs to be a really concerted effort on multiple tiers of the health care system,’ Dr Chiller says…

‘We need to stay on top of it and not let our guard down.’   (A)

“New York State health officials are considering rigorous new requirements for hospitals and nursing homes to prevent the spread of a deadly drug-resistant fungus called Candida auris.

The requirements could include mandatory pre-admission screening of patients believed to be at-risk and placing in isolation those patients who are infected, or even those just carrying the fungus on their skin.

Dr. Howard Zucker, the state health commissioner, and a fungal expert from the federal Centers for Disease Control and Prevention met last Friday in Manhattan with nearly 60 hospital officials from across the state to discuss the proposed guidelines. State health officials said they were seeking hospital input before issuing the guidelines, which they acknowledged would likely be a hardship for some institutions.

“One of our guiding objectives is to stop the geographic spread,” said Brad Hutton, the state’s deputy commissioner of public health. He said the state’s efforts to contain the spread have required significant resources — including sending individual infection specialists to investigate more than 150 cases — and that New York now needs help from individual institutions.

“We’re at a point where our response strategy needs to change,” he said. He added that he hoped the guidelines would be finalized by the end of the year, but said the state is still determining whether to apply them statewide or just to New York City and surrounding areas. It has yet to be decided whether the guidelines would be recommendations or regulatory requirements, he said…

For the moment…. hospitals are pre-screening many patients who appear to be at risk. But it can take a week to get skin-swab results back from the state laboratory, posing challenges for housing patients in isolation during the interim. Further, she said, regular testing is likely to turn up patients who are carriers but not infected, increasing the number of patients who require isolation, appropriately or not.”..

For now, much of the burden for surveillance has fallen to the state. The effort has involved the development of a fast-screening test that can analyze a skin swab in a matter of hours. But all hospitals, for the moment, have to send those tests to a state laboratory in Albany and wait several days before receiving the results, though hospitals say the backlog means tests can take a week.” (B)

“Unlike cholesterol drugs taken by millions of people for their entire lives, or $100,000 cancer drugs designed to prolong life, antibiotics are short-term drugs with limited shelf lives.

“Antibiotics are not valued by society as a high-value product, so they’re not priced very high,” said Gregory Frank, director of infectious disease policy at the Biotechnology Innovation Organization, in a phone interview.

A 2014 paper.. cited a London School of Economics study showing that while a new arthritis drug’s net present value – a measure of a drug’s net value over the ensuing decades – would be $1 billion, that of a new antibiotic would be negative $50 million…

People will buy innovative products in almost any other part of the economy, but doctors will still keep even the most innovative antibiotic behind the glass and use it only in the most dire circumstances.

“Antibiotic stewardship is a good thing, but devastating for the company developing it,” Outterson said…

Jersey City, New Jersey-based Scynexis is one company developing a treatment for drug-resistant fungal infections, ibrexafungerp, currently in several clinical trials, including one for C. auris. The company plans to file its first approval application with the FDA for ibrexafungerp next year. The drug is expected cost $450-600 per day, in line with the pricing of other antifungals, said company CEO Marco Taglietti, in a phone interview…

The race against drug-resistant infectious is ultimately a scientific one.  It’s not about finding better treatments, but newer ones in an endless war that requires always staying one step ahead of ever-evolving germs, Taglietti said. On the one hand, it’s important to practice good stewardship in order to delay resistance.

“But that creates a big challenge from an economic point of view – from the moment you launch your product after spending several hundreds of millions to develop it, it doesn’t sell,” he said.

The problem appears to be a vicious cycle of science and economics: Even existing push incentives, however generous, don’t make up for antibiotics’ lack of the large and chronic patient populations of cardiovascular disease drugs or the high prices of cancer drugs.” (C)

“Demanding that hospitals release lists of every superbug they find within their walls, however, as many transparency advocates want, is not the answer. The irony is that the hospitals that see the most superbugs are often the best ones we have, for the simple reason that they have the most sophisticated diagnostic platforms, the most powerful antibiotics and the experts to administer them.

Compelling a world-class hospital like Massachusetts General Hospital, where I saw my first superbug as a medical student, to reveal a microbe list would only freak patients out. It wouldn’t explain where the microbes came from, whether any patients were infected, and how they were cured.

In a worst-case scenario, more transparency could lead to patients avoiding medical care out of a misplaced fear of encountering drug-resistant bacteria. Hospitals might start refusing patients with certain infections, especially those coming from nursing facilities where these microbes are common, out of a concern that the patient’s bacteria could be added to the list. This would do everyone a disservice: Patients wouldn’t receive optimal care and superbugs would multiply.

But hospital administrators and government officials do need to be honest about the microbes in our medical centers and explain what is really going on. No comment will no longer suffice. People have questions and this story is not going away. To ensure that patients are well-informed, hospitals should train spokesmen to address these issues and states should revisit their reluctance to disclose information. Above all, health care workers and administrators should speak openly about the measures their hospitals are already employing to keep people safe.

I’m not particularly interested in the microbes that dwell inside of a given hospital; what matters is whether its employees follow the strict protocols that prevent these organisms from going where they shouldn’t…

Silence and evasion gives the perception that this is a problem spiraling out of control when, in fact, it’s not. An intricate tracking system exists so that epidemiologists across the country can monitor any outbreaks to ensure that proper protocols and containment strategies are implemented. We need to hear more from these superbug hunters.” (D)

“A new study published in the Journal of Occupational and Environmental Health has established protocols for containing the drug resistant Candida auris (C. auris ) in an animal facility, and by doing so, has identified four simple rules that can potentially be adopted by healthcare facilities to limit exposure to staff and patients. The study found that their double personal protective equipment (PPE), work ‘buddy’ system, disinfection and biomonitoring protocols were effective at containing high levels of C. auris infection within their animal facility, even six months after their experiments…

Before entering the animal holding and procedure rooms, staff donned a second layer of booties, gloves and gowns, which were later removed and placed in biohazard bins before exiting the rooms. Handling of infected cages and equipment was restricted to biosafety cabinets where a buddy system was implemented so that one person handed clean cages and supplies to a second person working inside the contaminated biosafety cabinet. This system-controlled workflow from clearly defined ‘clean’ to ‘dirty’ areas and allowed workers to monitor each other to ensure proper procedures were followed. Surfaces and equipment that came in contact with infected mice or tissues were treated with a strict disinfection protocol of 10% bleach followed (after five minutes) by 70% ethanol. The effectiveness of the workflow and protocols were continually monitored using swab testing on surfaces suspected to be contaminated, and as a second measure, Sabbaroud dextrose plates were placed inside the biosafety cabinet and on the floor underneath to determine whether C. auris was aerosolised within the cabinet or whether any debris contaminated the floor.

The researchers found that possible contamination came from direct contact with the infected mice or tissues but not from aerosolisation.” (E)

“A pernicious disease is eating away at Roy Petteway’s orange trees. The bacterial infection, transmitted by a tiny winged insect from China, has evaded all efforts to contain it, decimating Florida’s citrus industry and forcing scores of growers out of business.

In a last-ditch attempt to slow the infection, Mr. Petteway revved up his industrial sprayer one recent afternoon and doused the trees with a novel pesticide: antibiotics used to treat syphilis, tuberculosis, urinary tract infections and a number of other illnesses in humans…

The use of antibiotics on citrus adds a wrinkle to an intensifying debate about whether the heavy use of antimicrobials in agriculture endangers human health by neutering the drugs’ germ-slaying abilities. Much of that debate has focused on livestock farmers, who use 80 percent of antibiotics sold in the United States.

Although the research on antibiotic use in crops is not as extensive, scientists say the same dynamic is already playing out with the fungicides that are liberally sprayed on vegetables and flowers across the world. Researchers believe the surge in a drug-resistant lung infection called aspergillosis is associated with agricultural fungicides, and many suspect the drugs are behind the rise of Candida auris, a deadly fungal infection.” (F)

OCTOBER 3, 2018

“A large Candida auris outbreak at a hospital in England appears to be linked to reusable patient-monitoring equipment, a team of researchers reports today in the New England Journal of Medicine.

The outbreak in the neurosciences intensive care unit (ICU) at Oxford University Hospitals involved 70 patients who were infected or colonized with C auris, a fungus that has become increasingly resistant to azoles, echinocandins, and polyenes—the three classes of antifungals used to treat infections caused by Candida and other fungal species.

An epidemiologic investigation and case-control study by investigators from the University of Oxford, Public Health England, and elsewhere found that the most compelling explanation for the prolonged outbreak was the persistence of the organism on reusable skin-surface axillary probes, a device placed in a patient’s armpit for continuous temperature monitoring.

“Our results indicate that reusable patient equipment may serve as a source of healthcare-associated outbreaks of infection with C. auris,” the authors of the study write.” (G)